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0073 JASON'S LANE - Health
73 Jason's Lane Osterville P A = 121 119 i a L COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SY ED PART A CERTIFICATION APR 2 4 2002 Property Address: 73 Jason's Lane TOWN OF BAR.NSTABLE Osterville, MA 02655 HEALTH DEPT. Owner's Name: Thomas Goudev Owner's Address: Same Date of Inspection: April 3, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 121 Osterville,MA 02655-0049 Parcel: 119 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: April 8, 2002 The system inspector shall su a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use, Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73 Jason's Lane Osterville, MA Owner: Thomas Goudev Date of Inspection: April 3, 2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in.310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. . Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the`Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box'. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73 Jason's Lane Osterville, AM Owner: Thomas Goudey Date of Inspection: April 3, 2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.363(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water . Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION. (continued) Property Address: 73 Jason's Lane Osterville, MA Owner: Thomas Goudey Date of Inspection: April 3, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 1I of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 • Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 73 Jason's Lane Osterville, MA Owner: Thomas Goudev Date of Inspection: April 3, 2002 Check if the following have been done: You must indicate`yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system.components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 73 Jason's Lane Osterville, MA Owner: Thomas Goudev Date of Inspection: April 3, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on:a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2001 - 75,000-gals.; 2000:-9 7.000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ______.gpd Basis of design flow(seats/persons/sgft,etc.). Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped on-Dec. 12195-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 Jason's Lane Osterville, AM Owner: Thomas Goudev Date of Inspection: April 3, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete _metal fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 12" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 4" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping. GREASE TRAP: None (locate on site plan) Depth below grade.: Material of construction: _concrete ._metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 i Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_ FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 Jason's Lane Osterville, MA Owner: Thomas Goudev Date of Inspection: April 3, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons " Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber;condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 Jason's Lane Osterville, MA Owner: Thomas Goudev Date of Inspection: April 3, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 4'x 6'with 4'stone-hand probed leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The pit had 18"ofwater on the bottom The scum line was at the same level. There were no signs offailure. The bottom to grade was approximately 6' The cover was approximately 10"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: . Depth of solids layer: Depth of scum layer: Dimensions of cesspool- Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition.of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 Jason's Lane Osterville, M4 Owner: Thomas Goudev Date of Inspection: April 3, 2002 Map: 121 Parcel: 119 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. QA� A00 i O 1 Qa- 30 3 A3 ag 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C x SYSTEM,INFORMATION (continued) Property Address: 73 Jason's Lane Osterville, MA o Owner: Thomas Goudey Date of Inspection: April 3, 2002 SITE EXAM Slope , Surface water , Check cellar Shallow wells Estimated depth to ground water '`feet Please indicate (check)all methods used to determine the high ground water elevation:. Obtained from system design plans on.record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:. topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain`. You must describe how you established the high groundwater elevation: The bottom of the leach pit to grade was approximately 6' Using the Barnstable topographic map and the Cape Cod Commission water contours maps the maps were showing approximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied, relating to the system!,the inspection and/or this report.ry 11 COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 Y TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 73 JASONS LANE OSTERVILLE, MA 02655 M121 P119 L114 Name of Owner CHRIS HEALEY Address of Owner: 73 JASONS LANE OSTERVILLE,MA 02655 .. Date of Inspection: 3122100 �• Name of Inspector: JOHN GRACE 1 am a DEP approved system inspector pursuant to Secdon 15.340 of Tide 5(310 CMR 15.000) - �•� �� kGLr Company Name: SEPTIC INSPECTIONS "- APR Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 R S Telephone Number: 608-564-6813 FAX 608-664-7270 t 1ply ,p 2040 CERTIFICATION STATEMENT ��, y i C;T Ze I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below:is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: r X Passes _ Conditionally Passes _ Needs FurtherjEvjaIuaon By the Local Approving Authority Fails Inspector's Signature: Date:3/22/00 The System Inspector shall s bmit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the . system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My Inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. ,Y revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 73 JASONS LANE OSTERVILLE, MA 02655 M121 P119 L114 Name of Owner CHRIS HEALEY Date of Inspection: 3122/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: A X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are Indicated below. B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination In all Instances.If"not determined",explain why not. n(a The septic tank Is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was Installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is Imminent.The system will pass inspection If the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass Inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced Na The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass Inspection if (with approval of the Board of Health): _broken pipe(s)are replaced _obstruction Is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 73 JASONS LANE OSTERVILLE, MA 02665 M121 P119 L114 Name of Owner CHRIS HEALEY Date of Inspection: 3/22/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,Method used to determine distance n&(approximation not valid). 3) OTHER n/a revised 9098 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 73 JASONS LANE OSTERVILLE, MA 02655AM121 P119 L114 _ Name of Owner CHRIS HEALEY Date of Inspection: 3/22/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is Identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.' Yes No X Backup of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. R E. LARGE SYSTEM FAILS: 4 You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system Is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. a y revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 73 JASONS LANE OSTERVILLE, MA 02655 M121 P119 L114 Name of Owner: CHRIS HEALEY Date of Inspection: 3122/00 Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following: ". Yes No X _ Pumping Information was provided by the owner,occupant,or Board of Health. X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this Inspection. X As built plans have been obtained and examined.Note If they are not available with N/A. ' X _ The facility or dwelling was Inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was Inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X _ Determined in the field(if any of the failure criteria related to Part C Is at Issue,approximation of distance is unacceptable)1 5.302(3)(b)I X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 73 JASONS LANE OSTERVILLE, MA 02666 M121 P116 L114 Name of Owner CHRIS HEALEY Date of Inspection: 3/22/00 ' FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:3 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system Inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage):'n/a gpd Sump Pump(yes or no): NO Last date of occupancy: Na COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous Inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:Na APPROXIMATE AGE of all components,date installed(if known)and source of Information: . THE SYSTEM IS 14 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73 JASONS LANE OSTERVILLE, MA 02655 M121 P119 L114 Name of Owner CHRIS HEALEY Date of Inspection: 3/22100 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of Joints,venting,evidence of leakage,etc.) THERE IS TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age is age confirmed by Certificate of Compliance(Yes/No): NO Age: Na Dimensions: 1000G L 8'6"H 6'7"W 4'10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:Na Scum thickness: Na Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural Integrity,evidence of leakage, etc.) n/a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) , Property Address: 73 JASONS LANE OSTERVILLE, MA 02655 M121 P119.L114. Name of Owner CHRIS HEALEY Date of Inspection: 3/22/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design(low: n/a gallonstday Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm"and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution Is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) NO-DISTRUBUTION BOX-SNAKED THRU PUMP CHAMBER: _ (locate on site plan) Pumps In working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9098 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION(continued) Property Address: 73 JASONS LANE OSTERVILLE, MA 02655 M121 P119 L114 Name of Owner CHRIS HEALEY Date of Inspection: 3/22/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)5 XN LEACH PIT leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Aftemative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD I'OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 1'OF WATER IN IT. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet Invert: n/a Depth of solids layer: n/a Depth of scum layer. Na Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C x SYSTEM INFORMATION(continued) Property Address: 73 JASONS LANE OSTERVILLE, MA 02655 M121 P119 L114 Name of Owner CHRIS HEALEY Date of Inspection: 3/22/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes Into house) �cck 0 o , 0 PA ai x revised 9/2/98 Page 10 of 11 i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73 JASONS LANE OSTERVILLE, MA 02655 M121 P119 L114 Name of Owner CHRIS HEALEY Date of Inspection: 3/22/00 ` r NRCS Report name: n/a ' Soil Type: Na Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet n/a Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records Checked local excavators,installers X Used USGS Data ` Describe how you established the High Groundwater Elevation.(Must be completed) UGSS MAPS AND CHARTS-10 FEET revised 9/2198 Page 11 of 11 TO OF BARNSTABLE ',ILO "ION SEWAGE # VILLAGE 05�P_0\�� ASSESSOR'S MAP & LOT �k9 ui INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 6 oo LEACHING FACILITY: (type) (size) NO.OF BEDROOMS !i BUILDER OR OWNER �S PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by j/'Z2. ZUp C) 'C/"L A Lo - 65 3° OC 5 TOWN OF BJARNSTABLE t ^T10N 9v--LAGE' SEWAGE # R✓` ASSESSOR'S MAP & LO- JNSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 10-CED LEACHING FACILITY: (type) P (size) Sr0✓`� NO. OF BEDROOMS ,,J BLUDER OR OWNER �✓v'\, `e PERMITDATE: COMPLIANCE ATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching acility) Feet Furnished by Al- aC7 O —beck-- I 3 i - a$ O Aa- 3o a �a- 30 AS- ag 3 83 - S� TOWN OF BARNSTABLE LOCATION ?5 SEWAGE # MOW VILLAGE ��� Z'//'//f ASSESSOR'S-MAP &LOT Z -INS,'ALLER'S NAME&PHONE NO. ,90121PZv/l/ 7 7C —-1 u SEPTIC TANK CAPACrry -anq i LEACHING FACILITY: (type) ,� (size) NO.OF BEDROOMS 13 BUILDER OR OWNER 7&v*4— PERMTTDATE: e"//o Q4 COMPLIANCE DATE: �`� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching.Facility S� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feettoleaching facility) ,1001 Furnished b a . 73 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for Dtgw5al 6potem Conotruction Permit Application is hereby made for a Permit to Construct( )or Repair(r**')0'an On-site Sewage Disposal System at: Location Address Lot No. e �� Owner's Name,Address and Tel.NO. j i/ � lil! 7-wr0e.V1 ��f1/�(1/� �tWta1v� ©15�er11I1lle .9' $owl Ins aller's Name,Address,and Tel.No. ,7 7�_q�Q9 Designer's Name,Address and Tel.No. �O/'t0� Type of Building: Dwelling No. of Bedrooms '3 Garbage Grinder(_W Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Z Revision Date Title Description of Soil tee, Nature of Repairs or Alterations(Answer when applicable) /®Oep J/pllw Lay", 10,G 5 fog e rU Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y t 's and Health. Signe .® Date Application Approved by Application Disapproved for the following reas ns Permit No. Date Issued ( +rfR, ..9.,�..'lT. ..•�f"+fM-�� '.".y�.y.--rtJE'J.,-'.:i;y,:,,,...I/�..4a�j ,.:4.r'F.�V :y,,r.�,a .`....a...y:. .. .�. �.' �i. •,i;1.M • { a�.,,-...j� V � a- :4 f a96of No. - `-Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,MASSACHUSETTS 2ppiication for )Dioogaf *Wem 'Cou5truction Permit Application is hereby made for a Permit to Construct( )or Repair(V an On-site Sewage Disposal System at: t Location Address or Lot No.. a Owner's Name,Address and Tel.No. 73 iASG�IS G�he T"G/r [/slew//le Ayr7 sQw r Installer's Name,Address,and Tel.No. ,''1_ Designer's Name,Address and Tel.No. Boy taGD 1�i Co�s��i�c�i®n Type of Building: Dwelling No.of Bedrooms '� Garbage Grinder( D Other Type of Building ��'—.S� yIL No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 0 gallons. Plan Date. 7//1/ZC0 Number of sheets 7— Revision Date Title Description of'Soil' C°Cti� Nature of Repairs or Alterations(Answer when applicable) cny51zll f 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y t is and o Health. Signe ® Date Application Approved by l f Application Disapproved for the following reas ns Permit No. ~" 'Date Issued i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - i` THIS IS TO CERTIFY,t at the On-site ewage Disposal System installed )or repair ✓�on eplaced( b d r)V f D�1�5 for installed Y K? as 73 ,fee_5 05'"W 4////-0 ert constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions se orth below:. ----- No. 1'..�.J �C./ �/'/ � Fee ------ i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lifSpOal bpgtem Con5trurtton Permit Permission is hereby granted to ��/ ;1`v GDP}/ to construct( )repair(vo'o)_an On-site Sewage System located at Z 3 7A',540 5' 6f7, and as described in the above Application for Disposal System Construction Permit. The applicanjrecognize, his r duty to comply with Title 5 and the following local provisions or special conditions. . All construction mu a co plet d within two years of the date below. Date: Iq Approved by 1 �� i 0 or 3043 1+. -,� t T • A V •'�� � GSM•{/ � � ,�: }i. 32 32 /000 GAS � C ti�� N 36 txz t7 -Z S e N i' � ',• - L S 6 0-- - y .( BUNIKIS�► `� it A, �r�,. t�a6 t ;o• LEGEND 1M SPOT' ELEVATION OAO CErgT11FiED Lpr PLa z EXI '1'II CONTOUR - - - 0 - - W �. '.M1SHED: SPOT ELEVATION IQ.0] Z 7' spay, Pli+lppEO CONTOUR 0 PFA, VtD BOARD �.t OF HEALTH 1 N -SAS rA ` L, f t. AGENT SCALE //r 319 DATE ' 7/�•.� ,,r Ey£NG/NEER/NG CO. lNG' Os r �'1%z. - ----- _ - CLIENT . QIS, EflE[� I CERTIFY THAN' THE PROP REGIST'ERE01 ,s ''.,f IVIL LAND JOB NO, VDU 4.o BUILDING SHOWN ' ON , T p" HIS P�"r N + OINEER,S� ,�URVEYORS�J DR. BY A , �� Nf CONFORMS TO THE ZONING _LAIi +r, _ OF BARNSTABLE MASS.: NO MAIN ST' 712 MAIN ^r CH BY= ._1P. P, , K", - IH, MASS. HYANNIS, _ .. .__ -7 /� , . • �. S' .i. SHEET-t_ OF Z. 'dy /f j-� �- D TE REG l'A NOD .SUAV+F�IAA� : •, ;'_ r LEAGi+I/IVG P/1' A 'MORE TH.A/v /� ram•... • .�_ �RAGi/ ?4"O/AM. ETER COWVC!rlfTE cops-*r. 'AMA44 OAF BAr*W4T TD 4RA�L':�i4N EXTR/'� q'PVC p/PE tieAvy C^ST/RON Go✓«,S/V.4LL BEUSFO . : .. CONCRETE y/.V. P/TCN /P`'/N OR1 VEy✓A Y D D,fl COVERS /B•OFR�' C4NGR�TE CD�VER CLEAN G ADE B,4CX �:L-L` t z-LAYER _ L/QU/O LEVEL • t O CAST i � p •o o �.• • • • .•..•.• • o a4o WASHED ,57-DIVE /O 00 CYAL. o • • • • • • • s d o O/TCl/ o • e StPT/C TANK BOX o � o • • $ • . • • • • o •� 3�4"_ / �I2• .•� /4-PE/r /T. �s� i ::s.; , I D • •EFFECTI�C e • /•V.45HE0 STaNE Q. • c , • • DEPTH o `"� . • o � • • • • • • • • � oo ` • ,r.••• a e n o • • • • • • • • • c P '1 — PREC457-SEEPAGE to, c• V. P/7 OR "IIIi l Nl/BRT EL E✓AT/ON S /- S % - • O/AM _�i_JFT. SEE TABULtT1QN INVERT AT Qv/LD/NG _L� FT. O/AM I �6' FT INLET SEPTIC TANK �) s. T pt/TLET SEPTIC TANK �--F G oR UND i�lflTfR TABLE I 1 Al INLET D/5TR/BUT/ON BOX �• FT SECT/O/�/ OF OtlTLETD/STIR/B1/T/old SY-STEM T�gBULATIDN /^ EACHINIG PT I FT LEA- Cf�//VG R/T FT. /LET L v/MENS/O N A�-- SCALE DES/GN CR/TERIA p/MENS/ON G Q FT. Mir/• � ', NUMBER OF BEOROO/t9S 3 SOIL LOG SD/A. TEST G,4R6AGED/SPOSAL.UN'T_ ', b ,•,�,--J TOT•4[. ESTIMATED FLOH/ 3 3 O 0.41.1DA�' DSO/L TEST �! SOIL TEST# } ! fELE✓. 3 y �' ELEY• OATS OF SOIL TEST L) A/ s NUMBER OF LOACH/N6 PITS_- RESULTS Av1T/VESSED BY ACHING PER P/•7 SQ FT. O PERC04AT/ON RATE Atl L F - S/„/1/VtIINCN S/OE LE 7 g- T ` p i+9.L� T� 2-0 MlN.�lNCH BOTTOM L,f,ACH//VG PER P/T S4• F PE1tCj),LA JN RATE 2 TOTAL LEACHING AREA Z `s+n FT. s� as � ,L RESERI�E LEACNlN6 AREA_ b 5Q. FT 2 �- 6 D 5 T• //V V, T/Z :.�, !"1 F>, / '-�"► Aso /✓'s L�4NE FL.,onj D6aE /Vl6ZR GGt�1NC 7It;. 1lN ST 3W�+1 $ .�oi� ,�lrf NOOWVa�H''47'�i� N�UNT'��1 � oor " �.e. E1 , CERTIFICATION OF SKETCH AND APPLICATION TOIL A DISPOSAL WORKS CONSTRUCTION 1,EltNll'l' (�VI'1'11OU'I'llESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated �g , concerning the property located at ,� �y°D�l �� ®5 le/"�/l/f meet#all of the following criteria: There are no%vellands within 300 feet of the proposed septic system ✓ Thcre are no private wells wilhin I Stl feet of the proposed septic system The observed groundwater table is 14 reel or greater below the bottom or the leaching racilily V There is no increase in flow and/or change in use proposed There are no variances requested or needed. f rc9 ._ SIGN ED DATE: 6A 4 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF 13ARNSTABLE NUMBER ]Attach a sketch plan of the proposed system. Also If the licensed Installer posesses a certified plot plan, (Ills plan should be submitted]. LOCATION S E W A G PERMIT NO. 14 I'l L A G E 34 JAI f/9 I N S T A LLER'S NAIVE DDRESS BUILDER OR OWNER w L_le 4�;P Z DATE PERMIT ISSUED -7_ - DATE COMPLIANCE ISSUED l� 6 Y �� � ��� J�dt�( �7 L' __-- zzL ;J`, n �� ":r Fps.... 41) THE COMMONWEALTH.OF MASSACHUSE17S BOAR® OF HEALTH . ................OF.......:......' ' 041c A ....................... Applira#iun for Mipaatal Morko Tongtrurtiun ramit Application is hereby made for a Permit to Construct (114 or Repair ( ) an Individual Sewage Disposal System at: 1 , .......V ................. Location-Address o. ... ���. or Lot ��f3/�giUrtJf / Owner A dr!.s a % . •. .• . ...........:.p...... wt. �.........•............. Address •���� U Type of Building ` Size Lot...&A..�..47- _..Sq. feet �., Dwelling—No. of Bedroom ...........................................Expansion,Attic (!i)" Garbage Grinder ( ) �l .�.�__..... No. of ersons....._.7�....._..... Showers — Cafeteria p., Other—Type of Building !� p (� ( ) a Desi Flow............................................gallons per Other fixtures -.-•--------•----------------------- W 'gng p person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No.................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosingta ( ) �/o �y / �-7 1-4 Percolation Test Results Performed by._ ,L2- .. (1 i.. s/ ........ Date..l._.7�(O__ '.�f ..... W minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 1�.�._ _._. 44 Test Pit No. 2..�,Z:_Q...minutes per inch Depth of Test Pit.................... Depth to ground water........................ W ._......----•••---••--•-••......------•-------•.... ..... ..... --------•-•••. D crip�Z�qf. 5�1.. - •..... ._._ ��rjbj 11 ---- -----•-------------•-•--------......------•----....-----•----•-••- W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..........................•-•---•----•------••••••-••-•.....•••.....---------••-•--•---•----........----••----••----------------------•--•-•----------•--------•----------------------•-•••.........---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ee sued by th bo o alth. Sig ed. F.. ... Ir/ to Application Approved By........ G ..............••...---- 7. Date Application Disapproved for the following reasons:..............................•-------...__.....-----------------------------------------------..----.......... --------------••••--------........'........-•'....------------------••-•--------------......•---^----------------.... .........--- Date Permit No......................................................... Issued_... -.1. Date 1 No.cr&_ ./ Fus.......................... THE COMMONWEALTH OF MASSACHUSETTS �---- BOARD E HEALTLJ /00 ...............0 F...... ::... ,.. ApplirFa#ion for DhipasFal Works. Tonotrnrtiun ramie Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at 1 , Location Owner d r s a '. .. �----............ . 'rU�✓' ...... 1. r` ,� ........................................ Installer Address Type of Building Size Lot.._ -..)-_� ...Sq. feet Dwelling—No. of Bedrooms.___._______ :. Expansio ttic (4 r Garbage Grinder. ( ) ---- P4 Other—Type of Building .- .. No. of persons............................ Showers Cafeteria ( ) a' Other fixtures . W Design Flow............................................gallons per person per day, Total daily flow............. :_.._ .._ ......_•-_gallons. WSeptic Tank—Liquid capacity............gallons Length___._ ___._:- Width...":,.......... Diameter._._:................ Depth x Disposal Trench—No..................... Width...................... Total Length Total'leaching area..... .__._..._ sq..ft Seepage Pit No---_-----_-------- Diameter '...... .:.____. Deptli'below.inlet.._... ..... Total ching arrea_. q. ------ --_s ft. Z Other Distribution box ( ) Dosin a ( y �y� ,t,, / ''" Percolation Test Results Performed by.:. S :�_ ._. /�!!...�SlS........ Date--L�-�rrt2-......170. - 1.4 ..__. Test Pit No. 1.C.?W..minutes per inch Depth of Test Pit.................... Depth to ground water........................ (z, Test Pit No. 224.Z _.minutes per inch Depth of Test Pit.................... Depth to ground water........................ T r D De cripdon �f Soil 0: �. 4C��'/ t , to Q�' , '"" /L1 ,D�d / { � '' .......... { Zt.- -C-'�-#1.Q 4.41.. ---- -------- --•----- --- - W UNature of Repairs or Alterations—Answer when applicable.......................................:....................................................... t -•--------•----------------------------------------•-----•-•------------•---•-------.......--•-------------------------------------------------------------------------------.._......_..------•-------- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not'to place the system in operation until a Certificate of Compliance has ee sued by th bo o ,�ifalth. Sigd_ 4 ,..::. :. ........................ ................................sate 1 Application Approved BY .-...:...........•..... ` --- ... ..................- Date Application Disapproved for the following reasons:---•----•-- -•-••-•-••-------•-- ........................................................Da.--............. ......................................••------------......-------•••-.........•--------------•-•••--------•-----------------------•---• -----------•••-•-------•-•-----•--•-••---•-••••-•-•--•---------- Date PermitNo.....•--•--••------------------.......................... Issued....................................................... Date n THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ; Ir '..........OF...... ? �'�' ' (9rdifiratr of f1 omplittnrr / IS T, CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.... . .. .................................... .. -- • •----- ---.•... ------........................._ 1 nstaller A ----------------------------•---------------- has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No _.. .....,��9,........... dated__.../!!_%L�7-"�"- ................ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE AII! ,SSA GUARANTEE THAT THE i SYSTEM WILL FUNCTION SATISFACTORY. DATE.--- Inspector-- f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . 4 r q ......................... No J FEE�, �.............. Perm>ssion is hereby granted....... ,._._ ..�.'..... to Con rust or,�Paar ��n ndrvid ev��a a Dis sal)9% at No. t--- ? , �g�1 /-CE _ .................. reet ` as shown on the application for Disposal Works.,Construction Per NO.. ___. ...... ated.....77A.7`�`d-'.... Board of �.Vit - DATE..7 7.2... ....................-----•---............ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS _ f ♦, i. YS ` 'R '4 ) t Irv & •. IT —'_—_ ,� '4, {, ,+ ile• ' - _ � f + _"� � rs k-fit x��•jr� g �,.f,. 04 77 s � a. 9 7 ij e i 14, ` scar. 7.t vK ry <4 N 3 L c'f► c H= V r t A: sAT :; .: S7 S ROBST BUNIKIS r ; atrrr i{ ` ` ..s. f { N a r. ✓ `m LEGEND z _ � 1� .4N SPOT` ELEVATION {.0,0 ' CERTIFIED PLQT _ PL� F G , ` 1S7`t CONTOUR ; 0 11 -3H E P'O-T E L.E-V A T_! O N 10 i 4 �svN s L� s 40 taliED CONTOUR p a 9 ®OARD OF: HE`A"LTH I N AGENT SCALE . -DATEi 7 ,C E E�ENGINEERING CO. ING� r - CLIENT I . CERTIFY THAT, THE' PRd*Fa 0t ►� QOS, EflEL REGI3TERED1 JOB No. 00 BUILDING SHOWN,` ON =.THIS `PI N'= VIL LAND CONFORMS TO THE ZONING. AW$ '�� d G'I_MEERSy� URVEItpRSV DR. BY 1: OF BARNSTABL°E;;' MASS. . s &,N0 MAIN' ST 712 MAIN T CH .t r U TH MASS. HYA N N I S, M A Z _r �. SHEETS_ OF .. - D TE ;�R :G L AMn S.(IIRVF.'IAA r:. AMP GEAC%,///vG P/?' ,q �► MORE: TNAN;,%2'••SEL0 VV �. /D:/•T M/�/: !iRA•D•� o4 .!4"APIA ETEl� CD GR,�T•E «�E .. � CONCRGTE JS+e4 V Y CA ST/RO/V C D 0/`°'R SNAL:L, 8,E ;Z/S E1b COMERS of/N. P/TCN /P'/N ,DR%VA-WAY I A _b .2 M/IV. CO/VCReTE .� ` GRADE CO DER CLEAN ,„S"rANO - L/QV/O LEMEL / BACx LL �d 4•,C.4$T i , '7-r.-irTrr-.-r+>rrrl•' - - y .. IRON PIPE .�c ZyLAYs{R' b M/N. 0/TGI/ I CJ O U' CrA4. o' ,a o 0 0 OF //e ,/e,. e • �.• •, • •-•.I.1 0 i %4' PEnt 'T. AI'ST, o t� v n WASHFO S727NE SCPT/C TANK o A • o . •. • • °.° '• o d BOX a .8 n • 1.. 80' • • • • Iola 0 41 t .� � ,�, , o c e ° °EFFECT/VE •�. � 6 3�4."_ / �2" o lE.i'x., .,�•_ w.,...: .: ,� ° ' ° • DEPTH o o I •4• v WA59ED 5740NE � 7 ' 1 • • o O 1 • • • 1 o G c.o . 1... _ a v'.: a t I • • . e s .'• • • v p ) — PREG457-SE.EPA6E..,. lNlie 7' &4RVAT/DNS o ro • � . . .. . • • e • o� P/7 OR E4U/V. /N✓ERT AT BUILDING': y?,JFT 6 INLET' SEPTIC TANG �y,J F'T. _ FT. O/f1M C(SEETC/L�T/D�l Ot/TLET SEPTIC -rAN AFT. /NL,ET O/5TR/DUT/ON BOX' �_ �_ FT. GROVNO WATER'TABLE SECT/O/A/ O F O t/TLET D/STR/B[IT/oN,BOX `� �•AFT. ' INLET LEACH/NG /��T 9 FT SEN/AGE ®/.SPOSAL SYSTEM TABULATION L EACHIlVG P/7" DE516AI CR/TER/e'l SCALE j4.. _ /_ o.. v/MEwS/0N_ A D/Al.ENS/aN $ T. NUMBER OF BEDROQM� 3 � D/MENS%ON - C Q FT M�'� -j GARBAGED/SPOSAL 4vN7T_ SOIL LOG TOTAL, ES7/M.4TE0 FLOC 3 3-'O GAG.�0�1 Y - SO L. TEST i4E/ SOIL TEST¢° 2 SD/L. TEST NUMBER OF 40ACN/Afa P/TS .I r`ELEK 3•v /^-ELEY, I� A OA TE OF SOIL TEST S/OF LEACH/NG PER PIT —SQ,. PT. 1? ? c7-„/'i►< 5 ' D - ? RESULTS k//TNESSED BY ` 60TTOM.4 ACHING P&K-P/T �� $Q. PT `�� ��.�' PERCOLAT/ON /�ATEs,71�'✓ �'c s S MI N INCH TOTAL 4E4G'H/1VG`ARE1'':. Z6 6 SQ..:-FT. 5 u (j5'c� t:L A1E�tCOLAT/ON RATE J(>i2: . T-+ t' r✓ RESERVEGEACN/NEAR A_.�G b'Sq. FT z 6 ., fa Mari /"! �.sT L.A V, Tip 5�, cy� r .407 12 057T �1/! 4- L 4 l l S �`A.�� s'r`�'✓ s �L��$ E�6E,r�J11�'s�1N. iER/ ;MC 70, ST N�l+JMA Af r .. E,� • ' 1' ND�Ol�iN�d7.WArv—0 .�/VCtiD �